Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
In The
Dental Clinic
2010
Version No. 1
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LIST OF CONTENTS PAGE NO.
. INTRODUCTION 4
. PURPOSE 4
3. TARGET AUDIENCE 4
. RESPONSIBILITY 4
. POLICY 4
. TRANSMISSION OF PATHOGENS 4
. DEFINITIONS 5
8. ABBREVIATIONS 6
9. PROCEDURES 7
INFECTION CONTROL INSIDE THE CLINIC
9.1 BEFORE RECEIVING THE PATIENT 7
A. PREPARATION OF THE DENTIST AND DENTAL NURSE 7
B. PREPARATION OF THE CLINIC BEFORE TREATMENT 9
C. PREPARATION OF THE PATIENT 12
9.2 DURING THE TREATMENT 12
9.3 PREPARATION OF THE CLINIC AFTER TREATMENT 13
9.4 FINAL CLINIC CHECK 15
13. DENTAL HAND PIECES AND OTHER DEVICES ATTACHED TOAIR AND WATERLINES 18
18. BLOOD AND BODY FLUID EXPOSURES AND POST EXPOSURE PROTOCOL 22
23. CONCLUSION 24
24. REFERENCES 24
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Infection Control In Dental Clinic
1. INTRODUCTION:
Infection control is one of the most vital and significant areas in dentistry. The protocols and procedures in this
manual relate to infection control in Dental Health Care settings, they follow the guidelines of the CDC
(Centre for Disease Control) for infection control in the dental health care settings.
Dental Health Care Professionals (DHCP) include dentists, dental nurses, oral hygienists, oral radiologist,
dental radiographers, dental laboratory technicians, dental trainees, administrative staff, house keeping, bio-
medical and maintenance staff, all of whom may be exposed to a range of infectious materials as well as
contaminated supplies, air or water.
The guidelines are designed to prevent or reduce cross infection between DHCP to patient, patient to DHCP
and from patient to patient. The manual sets out step by step procedures to be followed inside the clinic before,
during and after treatment.
Procedures are also included for infection control in CSSD, Dental Radiology Department, House Keeping and
waste disposal guidelines are also detailed.
Infections:
Dental patients and DHCP can be exposed to pathogenic micro-organisms and other viruses and bacteria.
These include cytomegalovirus (CMV), HBV, HCV, herpes simplex virus types 1 and 2, HIV, Mycobacterium
tuberculosis, staphylococci, streptococci.
2. PURPOSE:
This manual consolidates recommendations for preventing and controlling infectious diseases and managing
personnel health and safety concerns related to infection control in dental settings in order to maintain high
quality of infection control standards at all times.
3. TARGET AUDIENCE
This is applies to all involved services of dental in the Health care facility hospital and all clinical staff should
familiarize themselves with the policy.
4. RESPONSIBILITY:
It is the responsibility of each staff member of the dental services to deal and to ensure that this policy,
procedures, and guidelines are implemented and followed meticulously.
5. POLICY:
The key to minimize the spread of infection is to decrease opportunities for cross contamination, especially in
clinic’s room where direct care is given.
To be used in conjunction with Health care facility manual of Infection Control
This policy should be implemented and followed by all dental clinic staff in order to provide a safe working
environment and to reduce\prevent the risk of cross- infection among patients and DHCP
Alcohol- based hand rub: An alcohol containing preparation made for reducing the number of viable micro
organisms on the hands.
Antiseptic: Germicide used on skin to inhibit or destroy micro organisms (e.g. alcohols, chlorine,
chlorhexidine, iodine).
Aerosols: Invisible contaminants suspended in the air. They are produced by the misuse of high speed suction,
ultrasonic scalars, use of prophy jets, and high speed cooled handpieces.
Colony-forming unit (CFU): The minimum number (i.e., tens of millions) of separable cells on the surface
of or in semisolid agar medium that give rise to a visible colony of progeny. CFUs can consist of pairs,
chains, clusters, or as single cells and are often expressed as colony-forming units per milliliter (CFUs/mL).
Decontamination: Use of chemical or physical means to remove, inactivate or destroy pathogens on a surface
or item.
Dental treatment water: Nonsterile water used during dental treatment, including irrigation of nonsurgical
operative sites and cooling of high-speed rotary and ultrasonic instruments.
Disinfectant: A chemical agent used on floors, walls or sinks to destroy most microorganisms.
Disinfection: Destruction of microorganisms by physical or chemical means. Disinfection is less lethal than
sterilization because it destroys the majority of pathogenic microorganisms but not necessarily all microbial
forms like bacterial spores.
Droplet nuclei: Particles <5 µm in diameter formed by dehydration of airborne droplets containing
microorganisms that can remain suspended in the air for long periods of time
Droplets: Small particles of moisture (spatter) generated when a person coughs or sneezes or when water is
converted to a fine aerosol mist by a handpiece. These droplets can contain infectious microorganisms.
Hand Hygiene: General term that applies to hand washing, antiseptic hand wash, antiseptic hand rub, or
surgical antisepsis.
Health-care Associated Infection (Nosocomial): Any infection associated with a medical or surgical
intervention.
Hepatitis B immune globulin (HBIG): Product used for prophylaxis against HBV infection. HBIG is
prepared from plasma containing high titers of hepatitis B surface antibody (anti-HBs) and provides
protection for 3--6 mos.
Hepatitis B surface antigen (HBsAg): Serologic marker on the surface of HBV detected in high levels
during acute or chronic hepatitis. The body normally produces antibodies to surface antigen as a normal
immune response to infection.
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Hepatitis B surface antibody (anti-HBs): Protective antibody against HBsAg. Presence in the blood can
indicate past infection with, and immunity to, HBV, or immune response from hepatitis B vaccine.
High-level disinfection: Disinfection process that inactivates vegetative bacteria, mycobacteria, fungi, and
viruses but not necessarily high numbers of bacterial spores. FDA further defines a high-level disinfectant as
a sterilant used for a shorter contact time.
Occupational Exposure: Skin, eye, mucous membrane, or parenteral contact with blood or other potentially
infectious material that can result in the daily work of a staff member.
Sterilization: Use of a physical or chemical procedure to destroy all microorganisms including substantial
numbers of resistant bacterial spores.
Surfactants: Surface active agents that reduce surface tension and help cleaning by loosening, emulsifying,
and holding soil in suspension, to be more readily rinsed away.
Vaccine: Product that induces immunity, therefore protecting the body from disease. Vaccines can be given by
needle injections, by mouth, or by aerosol spray
Washer- disinfector: Automatic unit that cleans and thermally disinfects instruments, by using a high-
temperature cycle.
8. ABBREVIATIONS
CDC : Centers for Disease Control and Prevention
CSSD : Central Sterilization and Supply Department
DHCP : Dental Health Care Professional
ER : Emergency Room
GP : General Practice
HIV : Human immunodeficiency virus
HBV : Hepatitis B virus
HVE : High volume evacuation
OPG : Orthopantomograph
OPIM : Other potentially infectious materials
PPE : Personal protective equipment
ICC : Infection Control Committee
ICM : Infection Control Manual
9. PROCEDURES
Infection Control inside the Clinic
9.1 Before Receiving the Patient:
A. Preparation of the Dentist and Dental Nurse
A.1 Hand Hygiene and Hand Care
Hand hygiene: (e.g., hand washing, hand antisepsis, or surgical hand antisepsis). The most
important factor in the prevention of infection is frequent and proper hand washing. The complete
practice of this activity substantially reduces potential pathogens on the hands and is considered
the single most critical measure one can take for reducing the risk of transmitting organisms
between patients and DHCP.
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Hand hygiene should be performed:-
Before and after treating each patient
• After touching inanimate contaminated objects with bare hands.
• When visibly soiled
• Before glove placement and after glove removal.
• Before leaving the clinic or dental laboratory.
• Before re-gloving after removing torn, cut or punctured gloves.
Duration
Method Agent Purpose Indication
(minimum)
Routine Water & non Remove soil and transient 15 seconds Before and after treating
hand-wash antimicrobial soap (e.g. microorganisms each patient (e.g., before
plain soap) glove placement and after
glove removal). After
barehanded touching of
inanimate objects likely to be
contaminated by blood or
saliva. Before leaving the
dental operatory or the dental
laboratory. When visibly
soiled. Before regloving after
removing gloves that are
torn, cut, or punctured.
Antiseptic Water & antimicrobial Remove or destroy 15 seconds Same as above
hand-wash soap (e.g. chlorhexidine, transient microorganisms
iodine and iodophors, & reduce resident flora
chloroxylenol, triclosan)
Antiseptic Alcohol-based hand rub Remove or destroy Rub hands until Same as above
hand rub transient microorganisms the agent is dry
and reduce resident flora (almost 20
second)
Surgical Water and antimicrobial Remove or destroy 3 minutes Before donning sterile
antisepsis soap (e.g. chlorhexidine, transient microorganisms Follow surgeon’s gloves for surgical
iodine and iodophors, and reduce resident flora manufacturer procedures
chloroxylenol, triclosan). (persistent effect) instructions for
Water and non- surgical hand-
antimicrobial soap (e.g. scrub
plain soap) followed by an product with
alcohol-based surgical persistent
hand-scrub product with activity
persistent activity
• Re-usable PPE (e.g. face-shields and goggles) should be cleaned with soap and water
when contaminated, and when visibly soiled disinfect with an intermediate- level disinfectant
according to manufacturer’s directions.
• Gloves and Masks must be removed before leaving the clinic.
• Gowns need not be removed if leaving the clinic to retrieve item/s from stock area, taking
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a patient to another area or if an emergency occurs requiring the help of other staff members.
A. 2.3 Gloves
All DHCP should wear clean non sterile gloves whenever
Double Gloving:
The effectiveness of wearing two pairs of gloves in preventing disease transmission has
not been confirmed. Studies have demonstrated a lower frequency of inner glove
perforation and visible blood on the surgeons hand when double gloves are worn.
These barriers need to be changed between every patient regardless of how minor the
treatment.
• Working Services
• The dental chair, the backs of the clinicians and assistants chair
• The overhead light, the UV light
• Hand pieces, triplex syringes
• Touch control panel.
• X-ray units, LED monitors
• Bracket Table Handle
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wrapping of a large quantity of trays or any other autoclaved instruments when setting up
your clinic.
• Bottled materials or plastic instruments that cannot be autoclaved should be sprayed and
wiped and sprayed again with a disinfectant before placing back into drawers.
• Anything on the counters or mobile carts not required for the procedure should be removed
to avoid contamination from aerosols that will be produced during treatment, which can
stay suspended in the air up to 60 minutes or more.
B.5 Handpieces
A sterilized handpiece is placed for each new patient, cover with film or plastic sleeve until
ready for use.
Impression Tray
• Commercially manufactured plastic impression tray is for single patient use only.
• Don not clean or reprocess then for subsequent reuse.
• After single use they should be disposed of in to clinical waste bag by the practice
or the dental laboratory.
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For skin disinfection, Effective and rapidly acting Not recommended for Available
Ethyl Alcohol 70% infant incubators, x-ray disinfectants (2 minutes) instrument disinfection.
(Ethanol) equipment and but they evaporate fast.
Isopropyl Alcohol thermometers
(Isopropanol)
Chlorhexidine 4 % For skin disinfection Invasive Procedures Not recommended for Available
handwash (Hand scrub) Theatre:- disinfecting instrument
Hands should be washed for and environmental
3 minutes surfaces.
Hydrogen Peroxide It is for endoscopes 10 Minutes Have Sporicidal activity Available
Concentrated and medical instrument and active at 10 minutes
"Perasafe" sterilant solution contact time.
Hydrogen Peroxide For cleaning and 10 Minutes High level surface Available
Surfactant Disinfecting of disinfectant.
"Virkon" surfaces Not recommended for
instrument disinfection
Hand Sanitizer Hand rub 20 -30 Seconds 62% alcohol Available
"Purell" Not recommended for
instrument disinfection
Hypochlorite And Equipment and 30 Minutes (Never mix acids with Available
Sodium environment hypochlorite since it
Dichloroisocyanurate disinfectant infant will release chlorine
(N.A.D.C.) incubators and infant gas) (not to be used for
feeding utensils. metallic surfaces and
instruments),
Ortho Phthal General disinfectant of 10 minutes as HLD Have no Sporicidal Available
Aldhyde (OPA) instruments. activity (not suitable for
cold sterilization)
Use in accordance with
the manufacture’s
recommendations.
Detergent Solution For ordinary cleaning 5 Minutes Will remove 80% of the
"Biotek" of surfaces microorganisms
A. Appointment:
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• The Dental Nurse removes the patients bib and ensures the bracket table is pushed out of the
way.
• The Dental Nurse removes gloves, washes hands and then gives the patient the next
appointment, (this may be done by the dentist).
• The Dental Nurse logs the case on the statistics sheet.
• The Dental Nurse then begins cleaning and preparing the clinic for the next patient by
following the procedures listed below.
C. Waste removal
• Dispose of used suction tips, saliva ejectors and air-water syringe tips.
• Place all contaminated waste in the yellow\red bags and all non contaminated waste
Black\white bag
• Place all needles and sharp objects in a puncture resistant sharps container, which should be
filled either up to the line or only two thirds capacity
• All rubbish bins should be filled to ¾ capacity only
• Flush through the waterlines of handpieces, ultrasonic scalers, and air-water syringes for 20-
30 seconds.
• Flush suction through with water after every patient to clean the inside of the suction of
residual micro-organisms.
Housekeeping Surfaces
CDC has divided noncritical surfaces in dental offices into clinical contact and housekeeping
surfaces. Clinical contact surfaces are surfaces that might be touched frequently with gloved hands
during patient care or that might become contaminated with blood or other potentially infectious
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material and subsequently contact instruments, hands, gloves, or devices (e.g., light handles,
switches, dental X-ray equipment, chair-side computers). Barrier protective coverings (e.g., clear
plastic wraps) can be used for these surfaces, particularly those that are difficult to clean (e.g., light
handles, chair switches). The coverings should be changed when visibly soiled or damaged and
routinely (e.g., between patients). Protected surfaces should be disinfected at the end of each day or
if contamination is evident. If not barrier-protected, these surfaces should be disinfected between
patients with an intermediate-disinfectant (i.e., EPA-registered hospital disinfectant with
tuberculocidal claim) or low-level disinfectant (i.e., EPA-registered hospital disinfectant with an
HBV and HIV label claim).
Most housekeeping surfaces need to be cleaned only with a detergent and water or an EPA-
registered hospital disinfectant, depending of the nature of the surface and the type and degree of
contamination. When housekeeping surfaces are visibly contaminated by blood or body substances,
however, prompt removal and surface disinfection is a sound infection control practice and required
by the Occupational Safety and Health Administration (OSHA)
• Clean housekeeping surfaces with a detergent and water or an EPA or CE registered hospital
disinfectant /detergent on a routine basis depending on the nature of the surface and type and
degree of contamination and as appropriate, based on the location in the facility, and when
visibly soiled.
• Clean mops and cloths after use and allow drying before reuse or using single use disposable
mop heads or cloths.
• Prepare fresh cleaning or EPA or CE registered disinfectant solutions daily and as instructed
by the manufacturer.
• Clean walls blinds and window curtains in patients care areas when they are visibly dusty or
soiled.
Note:
For more details refer to housekeeping manual
B. Waterline Sampling
• Water samples will be collected randomly from the waterlines in clinics on a quarterly basis.
• Bacteriology and environmental flora analysis of water samples is carried out by health care facility
Pathology Laboratory.
• Samples will be collected by an infection control member or their designee.
• Print clearly details of clinic and clinic number on the label.
• Remove lid of sterile container, run high speed handpiece with water on into the container until
approximately ¼ full.
• Replace the lid on the container and place in the appropriate collection bag.
• The recommendation by EPA is <500 CFU/ml
C. Water Supply
• Water supply is tested every two weeks for bacterial and chemical analysis.
• Every two weeks water supply is tested for hardness, total dissolved salts (TDS), alkalinity (pH), iron
content and conductivity.
The American Dental Association recommends that surgical and other instruments that normally
penetrate soft tissue or bone (e.g., extraction forceps, scalpel blades, bone chisels, periodontal scalers,
and surgical burs) be classified as critical devices that should be sterilized after each use or discarded.
Instruments not intended to penetrate oral soft tissues or bone (e.g., amalgam condensers, and
air/water syringes) but that could contact oral tissues are classified as semicritical, but sterilization
after each use is recommended if the instruments are heat-tolerant. If a semicritical item is heat–
sensitive, it should, at a minimum, be processed with high-level disinfection. Handpieces can be
contaminated internally with patient material and should be heat sterilized after each patient.
Handpieces that cannot be heat sterilized should not be used. Methods of sterilization that can be used
for critical or semicritical dental instruments and materials that are heat-stable include steam under
pressure (autoclave), chemical (Cidex or Perasafe ) vapor, and dry heat (e.g., 320ºF for 2 hours)
Patient-care items (dental instruments, devices, and equipment) are categorized as listed:-
1. Critical Instruments:
These are instruments used to penetrate soft tissue or bone, or have the greatest risk of transmitting
infection. These should be sterilized by heat.
2. Semi-critical Instruments:
These instruments touch mucous membranes or non-intact skin, and have a lower risk of transmitting
micro-organism. As most instruments in dentistry are heat tolerant, they should also be sterilized by
using heat.
3. Non-critical instruments:
These instruments pose the least risk of transmission of infection, contacting only intact skin. These
items may be immersed in a liquid chemical sterilant thus achieving high-level disinfection.
If cleaning is difficult or will damage the instrument, then use of disposable barrier protection may be
considered as an alternative
Patient-Care Items
Category Definition Dental Instrument/Item
Critical Penetrates soft tissue, contacts bone, enters into Surgical instruments, periodontal
or contacts the bloodstream or other normally scalers, scalpels, bone chisels,
sterile tissue surgical dental burs
Semi-critical Contacts mucous membranes or nonintact skin; Dental mouth mirrors, amalgam
will not penetrate soft tissue, contact bone, condensers, re-useable dental
enter into or contact the bloodstream or other impression trays, dental handpieces
normally sterile tissue
Non-critical Contacts intact skin Radiograph head/cone, blood
pressure cuff, facebow, pulse
oximeter
11.4 Sterilizers
• Sterilizers vary greatly in the types of indicators and their ability to provide readings on the
mechanical or physical parameters of the sterilization process. (e.g. time, temperature and pressure).
Consult the sterilizer manufacturer regarding the use and selection of indicators.
• Steam sterilization is most widely used for wrapped and unwrapped critical and semi-critical
instruments that are not sensitive to moisture or heat.
• Follow the manufacturer’s instructions for proper use of sterilizers.
• Packages should be allowed to dry in the sterilizers before being removed.
11.5 Instrument Processing Area:
• In CSSD all processing areas are separate.
• The central area is divided into four sections:
• Receiving area
• Cleaning and decontamination area
• Sterilization area
• Storage area
Recommendations
• Use water that meets standards for drinking water.
• Consult with the dental unit manufacturer for appropriate methods and equipment to maintain the
recommended quality of dental water.
• Discharge water and air for a minimum of 20-30 seconds after each patient from any device connected to
the dental water system that enters the patient's mouth (e.g., hand pieces, ultrasonic scalers, air/water
syringes).
13. DENTAL HAND PIECES AND OTHER DEVICES ATTACHED TO AIR AND WATERLINES
Because they retract and retain patients materials, dental hand pieces and other devices used in the mouth and
connected to the dental units air lines and water lines must be heat sterilize between patients. Components of
these devices are prone to contamination from contact with gloves and droplet spatter should be protected
with a new surface barrier for each patient and cleaned and disinfected when visibly contaminated.
• Clean and heat-sterilize hand pieces and other intraoral instruments that can be removed from the air and
waterlines of dental units between patients.
• Follow the manufacturer's instructions for cleaning, lubrication and sterilization of hand pieces and other
intraoral instruments that can be removed from the air and waterlines of dental units.
• Do not advise patients to close their lips tightly around the tip of the saliva ejector to evacuate oral fluids.
• Before removing the hand piece from the hose after treatment, with the bur still in the chuck, briefly run
the water/air system to flush water lines and airlines.
• Remove the bur from the hand piece, wipe visible debris from the outer surfaces of the hand piece, and
disconnect the hand piece from the hose.
• If the hand piece requires lubrication before heat-processing, use a hand piece cleaner recommended by
the manufacturer that will both remove the initial debris and lubricate the hand piece.
- If the hand piece does not require lubrication before processing, use a cleaner that does not contain a
lubricant.
- Follow the manufacturer's instructions for each type of hand piece used.
- Do not over lubricate hand pieces.
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• Reattach the hand piece o a hose and operate the drive air system to blow excess lubricant from the
rotating parts.
Failure to perform this step before heat sterilization can lead to excess lubricant accumulation in the working
assembly and gumming in the rotating assemblies during the heat cycle.
Complete elimination of the retraction valve in the unit is the most effective means of solving this
problem, but, with present dental unit designs, this may result in water dripping onto the patient. A viable
alternative is the installation of a check valve (anti-retraction valve) downstream from the retraction
valve. Installation of a check valve resulted in an almost 4,000-fold decrease in this contamination. The
attachment of a check valve will have no effect on normal less virulent bacteria already present in tap
water. These bacteria colonize the water lines of the dental unit and are then continually shed into the
water in numbers often as high as 1,000,000 CFU/ml.
Reference:
Journal of the American Dental Association, Vol 109, Issue 5, 712-716
Hepatitis B virus
Hepatitis is an acute or chronic inflammation of the liver caused by bacterial or viral infection, parasitic
infestation or chemical agents.
HBV Vaccination
Immunization of DHCP before they are placed at risk for exposure remains the most efficient and effective
use of vaccines in health-care settings.
• All DHCP should be vaccinated against Hepatitis B virus (HBV). A vaccination currently is only available
for HBV.
• Test dental healthcare personnel for anti-HBs 1-2 months after completion of the 3-dose vaccination
series.
• Provide employees appropriate education regarding the risks of HBV transmission and the availability of
the vaccine.
• Employees who decline the vaccination should sign a declination form to be kept on file with the
employer.
Precautions:
1. Vaccination against HBV for all DHCP.
2. Standard Precautions:
These include all the procedures mentioned previously:
Personal Protective Equipment (PPE)
Hand hygiene before and after treatment.
Disinfection of all surfaces.
3. All procedures should be performed in a way which minimizes the formation of droplets, spatter and
aerosols, utilizing high volume vacuum aspirators, rubber dams where appropriate and proper patient
positioning.
4. Avoid the use of instruments which cannot be easily sterilized.
5. After the procedure, all surfaces inside the clinic and equipment should be cleaned and decontaminated with
appropriate disinfectants.
6. These procedures are followed for all patients, whether they are infectious or not. All patients are considered
potentially infectious.
Even though the transmission of HIV in dental settings is extremely low, you should be aware of the
following:
• Increase risk of HIV infection is associated with exposure to a relatively large volume of blood as indicated
by a deep injury with a device that was visibly contaminated with the infected patient’s blood.
• The risk is also increased if the exposure was to blood from patients with late stages of AIDS.
18. BLOOD AND BODY FLUID EXPOSURES AND POST EXPOSURE PROTOCOL
Refer to Infection Control Policy on blood and body fluid exposures and post exposure
Mistake 1: The use of both hands to recap needles, this may cause needle-stick injury
Correction: Use a needle protector device
23. CONCLUSION
Infection Control in the dental setting plays a vital role in total patient care. Cross- contamination can easily
occur if guidelines are not set and followed.
All DHCP should be informed, trained, updated and monitored regularly to ensure that all implement the
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Infection Control protocol.
This manual will be of use in increasing infection control awareness to all DHCP in the Dental Center.
DHCP should always keep in mind that total patient dental care involves a multitude of factors that all play a
role in the delivery of the best care possible.
24. REFERENCES
CDC Guidelines for Infection Control in Dental Health-Care Settings – December 19, 2003
Disclaimer:
The contents of Guidelines for Infection Control were gathered from CDC, OSAP, ADA and OSHA. Care
has been taken to confirm the accuracy of the information present.
Our Resources and recommended reads
· www.cdc.gov
· www.osap.org
· www.ada.org
· www.osha.gov
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